Psychological impact of COVID‐19 pandemic and lockdown among the population involved in tourism sector in Lakeside of Pokhara: A qualitative study

Abstract Background and Aims The COVID‐19 pandemic has exerted a substantial influence on every sector of people's lives worldwide, including Nepal. The tourism industry is not exceptional. Lakeside Pokhara is one of the country's major tourist hubs and relies both on national and international visitors. The people residing in this area who depend on tourism‐related businesses to regulate their daily living faced numerous stressors and psychological impacts due to the pandemic. This study aimed to explore the COVID‐19 pandemic‐related stressors and their psychological impact among people dependent on the tourism business in the Lakeside of Pokhara, located in the Gandaki Province of Nepal. Method Via the qualitative approach, semi‐structured in‐depth interviews were conducted to collect the data from 20 individuals related to tourism business stakeholders in Lakeside of Pokhara. Thematic analysis was performed to analyze the data. Results The study found business‐related stressors among the people dependent on the tourism businesses, and these stressors were found to increase the experiences of psychological issues, including suicidal ideation. The pandemic has not only affected their economy but has also had an impact on their personal, familial, and social life. However, to combat the problems most of the study participants were found to be utilizing positive coping mechanisms, whereas some respondents were observed to consume more alcohol as a negative coping strategy. Conclusions People indulging in the tourism sectors were at greater risk of vulnerability in the future pandemic. Tourism business stakeholders struggled to combat the numerous stressors and psychological impacts carried out by the COVID‐19 pandemic and lockdown. Therefore, there is a growing need for government bodies to implement favorable business‐related policies, and Mental Health and Psychosocial Support (MHPSS) related programs to these stakeholders.


| BACKGROUND
A novel coronavirus named severe acute respiratory coronavirus 2 (SARS-CoV-2) was first identified in Wuhan City, Hubei Province in China, at the end of 2019. 1 Since then, it has infected over 173.2 million people in the world. As of January 25, 2023, there have been 664 million confirmed cases of COVID-19 and almost 7 million deaths. 2 The first case of COVID-19 was identified on 23 January 2020 in Nepal and the second case on March 24, 2020. 3 After confirmation of the second case, the Government of Nepal announced a nationwide lockdown from March 24, 2020. Even domestic and international flights were stopped to prevent the entry and spread of COVID-19 into the country. 4 Similarly, Nepal was hit by a second wave of COVID-19 in mid-April 2021 and the daily infection rate intensely increased to almost 10,000 persons per day from 300+ persons per day within a month. As a result, the Government of Nepal decided on a national-wide lockdown from April 21, 2021. 5 All the transportation systems, including flights and other business-related activities were deserted as in previous lockdowns.
The COVID-19 pandemic caused huge disruptions in almost all industries in Nepal and tourism being one of the largest industries of Nepal was not an exception. It was estimated that Nepal has lost more than $300 million due to the lockdown enforced in the wake of Covid-19. 6 Similarly, COVID-19 related restriction led to plunged Gross Domestic Product (GDP) and by a steep 46.6 percent in 2020. 7 Tourism revenue in 2019 accounted for 7.4% of the country's GDP and supported more than 1.16 million jobs, with the expectation of providing more than 1.35 million jobs by 2020, however, only 1.09 million jobs were created in 2020 and 1.06 million in 2021. 7 With the onset of 2020, Nepal government had planned to launch an ambitious tourism campaign "Visit Nepal Year 2020" with the theme of "Life time experience" and for this government had targeted two million international tourists by the end of 2020. To acknowledge the campaign, tourism stakeholders had planned to positively affect infrastructure development and create huge public and private investments in the tourism and hotel sectors in 2020. 8 Unfortunately, the campaign had been postponed due to the COVID-19 outbreak, which led to declining tourist arrival in the country. While compared to the previous numbers of tourists in 2019, the decreasing rate of tourists in 2020 was 1.96% in January, 1.00% in February, and 73.26% in March. 9 Mental health is "a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stressors of life, can work productively and fruitfully, and is able to make a contribution to his or her community." 10 The effect of the current COVID-19 pandemic on global mental health has not been registered and measured sufficiently. While COVID-19 is likely to bring both short-term and long-term mental health consequences, but the existing research findings has majorly focused on immediate mental health issues; therefore, it urges more in-depth studies on COVID-19 and mental health. 11 A study conducted among 1257 healthcare workers in China found that more than half of the healthcare providers had experienced the symptoms of depression, anxiety, insomnia, and distress. 12 The COVID-19 pandemic will substantially involve different phases with regard to mental health. 13 The first is the acute phase when people become aware of national and local causes, and steps are taken to limit the spread of the disease. Changes like lockdowns and school closures can trigger acute stress reactions and adjustment issues and can exhibit insomnia, paranoid traits, and disruptive behavior as they attempt to cope with the strain. Suicidal feelings have also been reported as the cause of the pandemic. This is followed by the sub-acute phase. 14 It has been anticipated that the global impact of COVID-19 is likely to last for several years. 15 People need to adapt to the new changed socio cultural circumstances, and this could result in stress, pathological habituation, anxiety, and more.
Mental health conditions after the COVID-19 pandemic has become the global concern. A survey conducted on the psychological impact of lockdown in Nepal suggests that about one-fourth of the responders had prominent anxiety (25.4%) and 7% reported depressive symptoms. 16 On the other hand, suicide became a major issue during the COVID-19 outbreak. During the first wave of lockdown in Nepal, the prevalence of suicidal behavior across nation compared with all of the previous year was relatively high. 17 Similarly, the health care professionals who worked in the health facilities of Nepal observed more self-harm and suicidal tendency during outbreaks with a rate of 3%−5%. 17 Similar, to other people, tourism-related professionals too should have been affected psychologically, but has remained to be unnoticed due to lack of research among this specific population. Hence, this study aimed to explore the COVID-19 pandemic-related stressors and their psychological impact among people dependent on the tourism business in the Lakeside of Pokhara, located in the Gandaki Province of Nepal.

| METHODS
The study was a cross-sectional qualitative study. The approval for conducting the study was obtained from the internal research

| Study settings
The study was conducted in the Lakeside area (Ward no. 6) of Pokhara, Gandaki Province, located in the western part of Nepal. It has a total population of 14,735 where 7008 are males and 7727 are females with a 3869 household population. 18 Lakeside is the hub for hotels, restaurants, travel essentials and trekking equipment shops.
The business in the area heavily rely on domestic and international tourists. 19 The district in the province had on top of the list of active cases of COVID-19 during the period of July 2021. The most of infected and the deceased are from the Pokhara Metropolitan City where the study area belongs. 20 The reasons for COVID cases were due to relaxing prohibitory orders and decreasing adherence to public health and social measures. 21

| Research participants
A total of 20 participants were interviewed purposively. By the time we interviewed 20 participants, there was no new information coming indicating the data saturation. The sample characteristics of the participants are provided in Table 1.

| Data collection
In-depth interviews were done using semi-structured interview guideline. All interviews were conducted in July 2021 using faceto-face interview technique. To avoid the risk of COVID-19 transmission, appropriate precaution measures were taken as suggested by WHO, and the Ministry of Health and Population (MoHP), Nepal. 22 Each interview lasted for about 45 min on an average. The interviews were conducted in Nepali language.
Informed verbal consent was taken with each participant before the interview considering the COVID-19 protocols. Among them, seven participants agreed to have their interview audio recorded, whereas the remaining 13 interviews were noted in the notebook.
Recorded interviews were transferred to a password-protected computer, followed by transcribing of the data, and the notebooks used to note the interviews were immediately checked for completeness. The interviews were then translated into English for the analysis purpose. R. P. and J. R. checked the quality and completeness of the translations independently.

| Data analysis
The data was analyzed manually using a thematic analysis approach. 23 Following the translation of the fifteenth interview, data T A B L E 1 Sample characteristics of the participants. analysis commenced. Two authors, R. P. and J. R., undertook independent coding of the first five interviews. Upon reaching a common consensus, subsequent interviews were coded separately by each author. The analysis was performed by categorizing the codes into three major themes (increase in business-related stressors, mental health vulnerability, and resilience).

| Findings
The findings of the study are organized in three major themes, which are further subdivided into sub-themes.

| Theme C: Resilience
Theme A: Increase in business related stressors The COVID-19 pandemic and subsequent lockdown measures have acted as a catalyst for an increase in stress among the general population. Both job seekers and business traders were experiencing various stressors due to the pandemic, with the severity and nature of these stressors proving to be unbearable. Common stressors among the business person included bank loans, government taxes and house rent, but newcomers in the business had been affected by the stressors as they have started business with the zero bank balance hoping for the profitable business in the future. Among these individuals, some participants expressed concern about not being able to meet their monthly loan payments.
"It has been less than four months since the business was established, and shortly thereafter, the govern- Additionally, families are struggling to meet the financial demands of their children, including regular expenses and school fees.
"Before lockdown, we used to work from office but in the past few month the COVID-19 forced us to stay at house with family. The family relationship was quite good previously, but spending all our time together has caused some misunderstanding to arise. Moreover, we must still consider school fees for our and adhere to family regulations as we did before, but the current situation is highly unfavorable for us." (Participants 3, 39 years, Male, Lakeside Pokhara) The ongoing crisis in the market has resulted in cessation in regular income for many individuals and has caused a notable increase in daily expenses. To make matters worse, certain bank balances that were saved for the future are now being depleted.
Meanwhile, some participants expressed concern over their children's lack of awareness regarding their family's financial situation. A female participant shared her experience as: "How beneficial would it be for us to consistently utilize our saved money throughout the year? We must also consider the future ahead. We, as a parents can understand the problem, but explaining it to our children is challenging. Children want the things to remain regulated as they were in the past, however,   Participants in this study were observed to exhibit resilience, as they constantly attempted to solve their problems and did not give up hope. Ram (pseudonym) a 29-years old active and friendly youth, shared that he coped with his emotional stress by confining in his close friends and family, allowing him to share the suppressed negative emotion and feel refreshed.
Finally, yet importantly, the traders were found to be coping mentally and practically until the day they were interviewed for this research. However, it is important to note that if they are forced to continue dealing with stressors fora long time, their resilience may be compromised.

| DISCUSSION
Three major themes emerged from the study, which includes business-related stressors, mental health vulnerability, and resilience.
The study found that major stressors for stakeholders in the tourism industry include bank loans, government taxes, and rent for the grocery. There is limited existing literature on the stressors discussed above, but one article emphasizes that many people perceived the COVID-19 pandemic as a greater threat to the economy than to their health. 24 Lower income is found to be associated with incidences of COVID-19 infections, but such economic factors are also altering many of the collateral effects of the pandemic. 25 Another study on Brazil's franchising stakeholders also backs up these study findings that the pandemic is putting a strain on the economy. Similarly, these study findings also support by the prior studies that found lockdown and halted trade have an influence on the families of business people in family relationships and child-rearing. 21  indebtedness, and inability to provide materially for one's family may increase stress and household conflict, undermine personal autonomy and induce feelings of shame and guilt. 40 Although, some of the studies are inconsistent with our study finding of the connection between financial uncertainty and, suicide and self-harm. 41 Several study found that in the first year of the pandemic, suicide rates appear not to have risen (and in some cases declined) in most countries for which evidence is available. [42][43][44] However, there might be a risk of suicide as many countries now are realizing the socioeconomic consequences of the pandemic which belongs to the indicators of poor mental health. [35][36][37][38][39] The findings of the study suggest that, despite some of the participants experienced mental health conditions, they did not receive the necessary mental health services. Moreover, the participants appeared to lack of awareness regarding mental health and help-seeking behavior. Stressors, stigma, and deteriorating mental health condition might have some connection with the suicidal ideation. However, there is no such study that has established a causal relationship between COVID-19 and suicide.
The third and final theme of our discovery was resilience.
Participants reported several behavioral, cognitive, and emotional coping methods, along with family and social support as resilience. resources. 45 Similarly, another systematic review on the resilience of entrepreneurs in times of crisis identified factors such as attitudes adopted towards the crisis, the characteristics of the business and the entrepreneur, the relationship with institutions, human and social capital, and strategic management. 46 Family and social support were seen as the other important factors associated with resilience. A higher and more significant perception of social support is associated with a reduced likelihood of developing psychological distress and psychiatric conditions. Adequate social support for the general population with regard to specific at-risk populations should be provided by offering targeted, tailored messages according to the most reliable scientific evidence. 47 Previous literature emphasizes the role of employing distraction strategies such as laughing and having fun, reducing social isolation and communicating through social media. 48,49 In our findings, participants were found to have an increased rate of alcohol consumption as a coping mechanism to tackle business-related stress. The media survey done by TPO Nepal during lockdown found that people are consuming alcohol as a coping mechanism, which has further added to the existing mental and psychological distress. 50 Similarly, the findings are consistent with research conducted on US adults, which found an increase in the rate of alcohol consumption as the COVID-19 lockdown began. 51 Comparisons before and during the COVID-19 pandemic were made on the number of days of any alcohol use and heavy drinking and the average number of drinks consumed over the past 30 days. 51 To sum up our study findings, common business-related stressors such as government taxes, bank loans, business rent, and skilled worker layoffs, and these stressors may be closely responsible for making business people mentally distressed and vulnerable. Similarly, in mentally distressed business people, insomnia, fatigue, suicidal ideation, and relapsing psychological disorders may be the most common symptoms. Meanwhile, by focusing on themselves, business stakeholders may be able to cope with stressors and mental distress.
Optimistic attitudes, alternative business models, and emotional support from family may be common stress coping mechanisms.

| Limitations
The study has some limitations. Because of the stigma associated with mental illness, there is a possibility of underreporting. However, privacy was maintained to reduce this issue. We were unable to contact those people who had closed their business completely due to pandemic effects. As the study was focused on Lakeside of Pokhara only, the findings cannot be generalized to other areas.

| CONCLUSION
This study showed that tourism business stakeholders of Lakeside of Pokhara, located in Gandaki province of Nepal are at risk of psychological problems because of excessive business-related stressors. Despite various ways to cope with stressors, the best coping mechanism for dealing with these issues were not known. There is a growing need for government bodies to implement policies regarding bank loans, government taxes, and house rent to rethink their future business. Mental Health and Psychosocial Support (MHPSS) intervention and related policies are found to be necessary to alleviate the stressors, and promote and strengthen psychosocial well-being among the tourism business dependent stakeholders.

CONFLICT OF INTEREST STATEMENT
The authors declare no conflict of interest.

DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available from the corresponding author upon reasonable request.

TRANSPARENCY STATEMENT
The lead author Rajesh Paudel affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.